| 1. Name of employer |
| 2. Workplace and address of workplace |
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| 3. Nature of business |
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| 4. Branch or department and exact place where accident occurred |
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| 5. Injured person's— |
| (i) Surname |
| (ii) Other names |
| (iii) Address |
| (iv) Sex |
| (v) Age at last birthday |
| (vi) Precise occupation |
| 6. Date and hour of accident |
| 7. Time injured person commenced work |
| 8. Nature of accident |
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| If caused by machinery– |
| (a) give name of machine and part causing accident |
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| (b) state whether machine was moved by mechanical power at the time of the accident 9. Extent of disablement |
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| 9. Extent of disablement |
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| 10. Date disablement ceased |
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| Date: |
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| Signature of Employer |